Forum - Questions & Answers

Mar 27th, 2015 - KINGRR 2 

Can documentation in Chief Complaint be counted under HPI?

The 1995 CMS E/M Documentation Guidelines state:
“The CC, ROS and PFSH may be listed as separate elements of history, or
they may be included in the description of the history of the present
illness.”

So can the documentation in the Chief Complaint also be counted under the HPI?

Example: “Patient presents with ear pain and a fever.”
Chief Complaint = Ear pain
HPI = Location (ear) and Associated signs/symptoms (fever)

All feedback is appreciated!



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